IHP 505 Module 3 Milestone One Example

Milestone One: Improving Access at Northgate Family Medicine

[Student Name]

Southern New Hampshire University

IHP 505: Leadership in Clinical Microsystems

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: Improving Access at Northgate Family Medicine

The microsystem assessment of Northgate Family Medicine found a cycle of long waits, missed appointments, overloaded clinicians and staff turnover, with access at its center. This milestone defines the improvement opportunity: what the access problem looks like in numbers, why it matters, what drives it, the aim of the improvement, how progress will be measured and what the project will and will not cover.

The Problem in Numbers

Over the past twelve weeks, the third next available routine appointment averaged 28 days across the clinic's nine clinicians, ranging from 12 days for one nurse practitioner to 45 days for the most senior physician. The no-show rate was 19%, rising to 27% for appointments booked more than three weeks ahead and falling to 6% for appointments booked within two days. About 30 patients a day called requesting a same-day visit, and roughly a third were sent to urgent care. Clinicians averaged two hours of documentation after clinic each day.

Understanding Supply and Demand

Murray and Berwick (2003) argued that long waits in primary care are rarely caused by a simple shortage of clinicians. More often, practices carry a backlog built up over time, mismatch supply and demand from day to day, use many appointment types that fragment the schedule and push today's work into the future. They recommended that practices measure daily demand, meaning all requests for appointments however they are handled, and daily supply, the number of appointment slots actually available, and then work down the backlog while matching capacity to demand.

A four-week count at Northgate found average daily demand of about 190 appointment requests, including same-day calls, follow-ups booked at visits and requests that went elsewhere. Average daily supply, after accounting for clinician administrative time and vacations, was about 175 slots. The gap of about 15 visits a day, combined with a backlog of roughly 1,100 booked future appointments, explains much of the wait.

Table 1. Access Baseline

Note. Figures are illustrative for the composite clinic.

Why It Matters

For patients, long waits delay care for problems that feel urgent to them, push them toward more expensive urgent care and emergency settings and weaken the relationship with their own clinician. For the clinic, missed appointments waste capacity and revenue, and urgent care visits fragment care. For the regional health system, which is entering value-based contracts, poor access undermines quality measures such as diabetes and blood pressure control, which depend on timely follow-up.

The Quadruple Aim

Bodenheimer and Sinsky (2014) argued that the familiar three-part goal, covering how patients experience care, how healthy populations become and what care costs, should become a quadruple aim by adding the well-being of clinicians and staff. They pointed to high rates of burnout, noting that burned-out clinicians and staff are associated with lower patient satisfaction and quality, and they described practice changes, such as sharing work across the team and reducing documentation burden, that can improve work life. At Northgate, where four of nine clinicians report burnout and a third of medical assistants left last year, any access improvement that simply adds visits to already full days would fail the fourth aim and likely fail altogether.

A Microsystem Problem

Nelson et al. (2008) describe microsystems as front-line units with their own aims, processes and outcomes, capable of improving themselves when their members study and redesign their work together. Access at Northgate is a microsystem problem: its causes lie in how the clinic schedules, communicates and shares work, not mainly in decisions made at the health system level. That means the clinic team, not an outside consultant, should lead the redesign, with the practice manager coordinating.

What Staff Think Is Driving the Problem

Before setting the aim, the practice manager asked each role what it believes causes the delays. Front-desk staff pointed to seven appointment types that make it hard to fit patients in and to clinicians blocking time without notice. Medical assistants named missing supplies and paper forms that slow rooming. Clinicians described visits crowded with issues patients had saved up while waiting, which makes each visit longer and adds to charting. The nurse care manager noted that many follow-up visits could be handled by phone or through her diabetes and blood pressure clinic. These views largely match the supply and demand analysis and add practical ideas the team can test, which is one advantage of treating access as a microsystem problem rather than a management directive.

Aim

Within nine months, Northgate will reduce the third next available routine appointment from 28 days to 7 days or fewer for all clinicians and reduce the no-show rate from 19% to 12%, while reducing average after-clinic documentation time from two hours to one hour or less.

Measures

Outcome measures are third next available appointment, measured weekly for each clinician; the no-show rate; and patient-reported ease of getting appointments. Process measures are daily demand and supply counts, the backlog of future appointments and the share of same-day requests seen at Northgate. Balancing measures, reflecting the quadruple aim, are after-clinic documentation time, staff overtime and a brief monthly staff well-being question. Continuity, the share of visits with the patient's own clinician, is also tracked, since access changes can disrupt relationships.

Scope

The project covers Northgate's scheduling, phone and rooming processes and team roles. It does not include hiring additional clinicians, which the health system has declined for this year, or changes to the electronic health record beyond template adjustments the clinic can make. These boundaries keep the work within the microsystem's control.

Risks

The main risk is that working down the backlog requires temporarily adding visits, which could worsen burnout before it helps. The plan will need to spread that effort fairly, perhaps through a few extra sessions shared among clinicians who volunteer, and to pair it with changes that remove work, such as handling some follow-ups by phone.

Conclusion

Northgate's access problem is measurable, meaningful and within the team's reach. Its causes appear to lie in backlog, supply-demand mismatch and fragmented work, and its solution must improve access without further burdening staff. The next milestone reviews evidence on how practices have done this.

References

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. https://doi.org/10.1370/afm.1713

Murray, M., & Berwick, D. M. (2003). Advanced access: Reducing waiting and delays in primary care. JAMA, 289(8), 1035-1040. https://doi.org/10.1001/jama.289.8.1035

Nelson, E. C., Godfrey, M. M., Batalden, P. B., Berry, S. A., Bothe, A. E., McKinley, K. E., Melin, C. N., Muething, S. E., Moore, L. G., Nolan, T. W., & Wasson, J. H. (2008). Clinical microsystems, part 1: The building blocks of health systems. The Joint Commission Journal on Quality and Patient Safety, 34(7), 367-378. https://doi.org/10.1016/S1553-7250(08)34047-1